Medicine, As Not Seen On TV

Since I was twelve years old, my life has taken place in a series of Four Year Intervals.

Four years of high school. Four years of college. Four years of medical school. Four years of residency. Four times four, nice and symbolic.

This comes to mind now because I finished my first year of residency today.

I went into it raised on a steady diet of medical TV dramas like Scrubs and House, the legends passed down by other doctors in my family, and the ideas inculcated into me in medical school. It turned out to be nothing like any of those.

But I thought this would be a good time to record – for my future self as much as for anyone else – what surprised me in my first year of medical practice.

To start with, forget about diagnostic mysteries. If you’ve ever seen House or anything else remotely like it, you imagine doctors as constantly presented with weird and wonderful symptoms, then racing against the clock to figure out what rare and deadly disease it is.

In real life, patients are more like the elderly lady I got last month. She had three hospital admissions for urinary tract infections in the past two years. Now she comes in with urinary symptoms. Before I even know the patient exists, the emergency room doctor has run a urine test which reveals that it’s a urinary tract infection. He has helpfully started her on the correct antibiotic for urinary tract infections. WHAT COULD THIS DIAGNOSTIC MYSTERY POSSIBLY BE?

Yeah, it was a urinary tract infection.

Or the guy who comes in shaking and sweating. I ask him what happened. He said he has been drinking alcohol for thirty years, and two days ago he tried to stop cold turkey. Have you ever had these sorts of symptoms before? Yes, every time I go off alcohol I get them. Does anything relieve the symptoms? Yes, drinking more alcohol. SOMEBODY PAGE DOCTOR HOUSE TO FIGURE OUT WHAT’S GOING ON?

Yeah, it was alcohol withdrawal.

Not all the patients I got were like this. But probably ninety-five percent of them were. Most people come into hospital for flare-ups of chronic problems they have had for, at minimum, ten years. Most of the time they have been to their primary care doctor first, who has made the diagnosis and sent the patient to the hospital for treatment. Or if not, they go to the emergency room, where the emergency room doctors do the same standard blood test they do on everybody and which usually gives you a really good idea what’s up. Oh, you’re feeling sick and tired and thirsty and nauseous? Hmm, your blood glucose is five hundred. Are you a diabetic? Did you take your insulin? Why didn’t you take your insulin? “Being on vacation” is not a good reason to stop taking your insulin! Do you promise to take your insulin in the future? Okay, well let’s admit you to the hospital and send you to Dr. Alexander so he can clear up this massive medical mystery we have on our hands.

But okay, five percent of cases we’re not entirely sure what’s going on. Now we can page Dr. House, right?

Wellll, in reality we “stabilize” them. A lot of the time “stabilize” means “put them in a bed and give them IV fluids and they get better on their own”. Sometimes the problem looks vaguely infectious and so we give empiric antibiotics, where empiric means “let’s give them an antibiotic that works for lots of stuff, and maybe it’ll work for this”. Sometimes the problem looks vaguely autoimmune and we give them steroids.

It’s pretty funny, because in medical school you spend a lot of time learning about maybe two dozen very rare autoimmune diseases, and how to differentiate Wegner’s granulomatosis from Takayasu arteritis, and the very subtle differences in the aetiology of each. And in real life, my attending says “Huh, this looks vaguely autoimmune, let’s throw steroids at it.” And it always works.

Now I understand that when the patient leaves hospital, they go to a rheumatologist or other specialist, and the specialist probably does lots of complicated tests and then comes up with a treatment regimen perfectly suited to that patient. But at the level I’m working at, it’s more “Hey, it responded to steroids! I guess it really was autoimmune! Or maybe the patient just got better on her own. Or something. Anyway, who cares, patient’s better, let’s discharge before something goes wrong.”

Because something else always goes wrong. You may be wondering: if doctors don’t spend their time solving diagnostic mysteries, what do they do in all those long hours they work? The answer is: deal with the avalanche of disasters that inevitably begin the second a patient walks through the door into a hospital.

I want to make it very clear I’m not criticizing my own hospital here. They make an amazing effort to do everything possible to avoid dangerous complications. All the hospitals I’ve worked at do. And all of them are death-traps. God just has a particular hatred for hospital patients, which He expresses by inflicting random diseases upon them for so long as they make the mistake of staying within the four walls and ceiling of a hospital building.

Like, you can be a perfectly healthy person, who lives forty years without anything worse than a sniffle. And then one day you’re playing sports, and you break your leg and you think “What’s the worst that can happen, I’ll spend a day or two in the hospital?” and by the time you come out you’ve got two artificial legs and a transplanted kidney and a rare bunyavirus from the African tropics and you have to inject yourself with insulin every three hours or else you die.

There are some good reasons for this. Obviously hospitals are full of sick people which means the potential for contagious infectious is high. People in hospitals are always getting lines stuck into them and surgeries performed and otherwise having foreign objects stuck in the body, and of course that’s a risk factor for all kinds of stuff. People in hospitals are often taking medications, which often have side effects. People in hospitals are often having tests, which sometimes involve injecting large amounts of radioactive material into the body and hoping it doesn’t fry anything important.

Then there are reasons you never expect until someone teaches you about them. If you don’t move your legs enough – maybe because you’re lying in a hospital bed all day – the blood in your legs settles and clots, and then the blood clots travel to your lungs, and then you can’t get any oxygen and potentially die. If you don’t fidget enough – maybe because you’re lying in a hospital bed unconscious – the constant pressure on a single patch of skin produces an ulcer, which gets infected and you potentially die. If you take five different recreational drugs every day, and your dealer doesn’t visit you in the hospital, then you go into withdrawal, and if you don’t want to admit what’s going on to your doctor maybe they miss it and – yeah, you potentially die.

But probably the biggest reason – and one you never think of – is that the hospital is where they’re finally doing tests on you, which means all those diseases that were lying dormant before and which you put down to normal old age finally get detected. You come in for a kidney stone, but your doctor does a blood test and finds you have diabetes. Also your calcium is a little off, we’re going to need to give you calcium pills and set up an appointment to get your parathyroid checked. And also when they did the CT of the kidneys they found a suspicious-looking mass in the colon, so you’re going to have to get that checked out. Uh, the gastroenterologist pulled the joystick controlling the colonoscope a little too hard and now you have a perforated colon, you need surgery. Uh, the surgeon put on her gloves the wrong way, now the surgical site is infected, guess you need antibiotics. Uh, guess you’re allergic to that antibiotic, let’s use a different one. Wow, allergic to four antibiotics in a row, guess this isn’t your day!

While Dr. House is diagnosing Chikungunya fever, the rest of us are treating the person who came in with a nosebleed (final diagnosis: blew nose too hard) but now has a DVT, hyperkalaemia, Sundowner’s syndrome, and a line infection.

Well, sort of treating.

John Searle came up with this really interesting philosophy-of-consciousness thought experiment. Suppose that a man were put in a room with a bunch of books, each of which contained a set of rules about Chinese characters. Sometimes, a paper with Chinese characters would come in through a slot in the door. The man would apply the rules in his book, which told him to write certain Chinese characters if certain conditions about the characters on the paper held true, and slip the output back through the slot in the door. The man does this faithfully, although he doesn’t know any Chinese and has no idea what any of it is saying.

On the other side of the door is a Chinese person. In her mind, she’s writing questions to the man, and he is responding back in fluent Chinese. She thinks they’re having a very productive conversation, and is starting to get a crush on him.

And the question is, in what sense can the man in the room be said to “understand” Chinese? If the answer is “not at all”, then in what sense can the brain – which presumably takes inputs from the environment, applies certain algorithms to them, and then sends forth appropriate outputs – be said to understand anything?

Daniel Dennett and various other materialist philosophers have a response to this challenge, which is that the man does not understand Chinese, but the man, his books, and the room can be conceptualized as an emergent system that does possess the property of Chinese-understanding and which may or may not be conscious.

I bring this up, because I understand what’s going on with patient care about as well as the man understands Chinese. I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.

Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.

The patient thinks “My doctor must be very smart”. Meantime, the girl outside that room in the thought-experiment is thinking “This man must be a brilliant Confucian scholar.”

Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work.

Well, other people are. I plan to go into outpatient.

Starting tomorrow, I abandon this exciting world of urinary tract infections and broken legs and go into psychiatry full time. I’m looking forward to it, especially since psychiatry is a little slower-paced and more focused. But this year was meant to teach me some appreciation for the wider world of medicine.

And boy have I got it.

[Good luck to SSC commenters Athrelon and Laura and everyone else starting an internship or residency tomorrow, and congratulations to everyone finishing one up]

65 Responses to Medicine, As Not Seen On TV

It seems like I know a fair number of people who took a long time to get diagnosed, or haven’t gotten a good diagnosis yet. It’s possible that either I run into more such people for some reason, or that they talk about their medical problems more than those who get reasonably quick diagnosis and treatment. Two examples: one with Cushings, and one with hypermobility– that turned out to be causing a lot of her chronic pain.

Because the people who are diagnosed quickly aren’t in the pool of people who’ve got a problem. When I had strep throat as a kid, my doctor figured it out and treated it in twenty minutes. When one of our friends has hypermobility that causes long-term joint pain, or Hashimoto’s Syndrome which affects her whole life, or it turns out that I have bipolar II which needs an entirely different treatment than the unipolar depression I had been being treated for — it’s BECAUSE those are less obvious that they don’t get diagnosed as easily. So they have them for longer, and they cause longer-term problems, and, indeed, have enough time to cause knock-on problems.

“There are some good reasons for this. Obviously hospitals are full of sick people which means the potential for contagious infectious is high.”

Scott- I asked about gluten, previously. You delivered an awesome answer.

May I ask for your thoughts on Ewald’s “infectious causation of disease” hypothesis? In short, it suggests that many illnesses and disorders that we don’t currently think of as caused by infections are very likely caused by infections. I think it’d go so far as to say that if there’s an illness that seriously degrades fitness, and we don’t know *what* causes it, it’s almost certainly caused by an infection.http://goo.gl/maKVWuhttp://en.wikipedia.org/wiki/Paul_W._Ewald

It occurs to me that, if this hypothesis is true, a hospital might be a particularly bad place to be if you’re sick / have a compromised immune system.

Reading your story about the elderly lady with UTI, I was reminded of my own troubles with getting diagnosed: one year out of the blue I started getting infections every couple months; this continued for 2 years and then stopped just as suddenly. Every time I went to the clinic, they would give me antibiotics which of course worked, but the main thing I wanted to know was whether I had an underlying problem that was causing all these infections or whether I was just really unlucky; and nobody could tell me that. So for me as a patient, life is still full of diagnostic mysteries.

Between this, Robin Hanson’s post on healthcare a few years back and your recent stuff on placebos, do you think we may have passed the point where we’ve exhausted the benefits of better medical technology?

I don’t mean that in the “Western Medicine is a Scam” BS sense, it’s pretty obvious it does it’s job treating illness extremely well, just pondering a bit. If a placebo is at least a fifth as effective as regular treatment and otherwise healthy people recover from illness even without sophisticated medical intervention most of the time, it seems like the main benefit of modern medicine is for people who for whatever reason couldn’t survive unassisted.

Looking at recent work on rising mutational load due to lowered infant mortality getting rid of purifying selection (not my term, that’s the actual scientific name) and the 8-13 point drop in genetic g since Queen Vicky’s day, it certainly seems that Plato’s complaint about ‘modern’ Athenian medicine weakening people’s constitutions might not be too far off the mark. Putting it on a more personal level, I know I and most of my immediate family needed some pretty fancy obstetrics just to survive delivery and even though we tend to be bright we’re a particularly odd bunch and not exactly the pinnacles of health either.

Again, not saying we should fire all of our cardiologists and spend the money on really charismatic witch-doctors or anything, just wondering how about how far out in terms of diminishing marginal return we are already.

The graph doesn’t show standard errors, but many of the studies have small standard errors, including those from 1888, so more data from 1888 is not needed.

The problem is that the difference between studies is large. Is this a real effect, or is there systematic difference between studies? This is not a question that can be resolved by more studies. A thousand studies from 1888 that all had the same mean would not explain the range of means today.

If the difference over a century is meaningful, then so too is the difference today. Then Finns and Australians are much faster than Americans. Woodley et al don’t notice that this follows from their methodology, probably because they are idiots, but maybe because they are frauds. If this is true, it is easy to test, unlike the conclusions they want to draw. More likely it is systematic differences between methods of measuring reaction time. That is my explanation. And it is very easy to test: just get the equipment from the various tests and apply them to a single sample of people. It doesn’t have to be a good sample; a classroom of undergraduates will do.

My doctor was trained in South Africa. Their training was, basically, “Here are the ten most common/most important to treat right away before you can call for help diseases, and here are the twenty most common/most urgent procedures you’ll need to know. Here’s how to improvise for stuff which you don’t know what it is, and here’s how to call for help if your improvisation doesn’t work. Here’s how to help set up reliable healthy water supplies and to check and fix other environmental stuff and clean up disease vectors. Here’s how to track and report disease patterns to a central authority. Okay, cool, it’s now six years later, which includes college, here’s the rural village you’re assigned to. It’s your job to make them healthy and keep them healthy, Doctor. You get good at that, and, in a couple of years, you could apply for positions in the cities or research positions, if you want to.”

Honestly, it was kind of similar to a residency — except that your attending was at least a phone call, and more likely a Jeep ride, away. He’s been a family practitioner in Boston for about thirty-five years now, and he believes that 95% of what you see is obvious stuff that you see all the time, and that, of the rest, about 3% will go away on its own, and 2% you just make your best guess and it usually works out, and, if it doesn’t, you hand it off to a specialist.

Of the 95% of what you DO know about it, most of that would go away on its own, and then there’s a lot of stuff you can’t do anything about. Setting bones, stitching wounds, immunizations, antibiotics for infections, helping people figure out how to eat healthier, encouraging people to exercise more, stop smoking, and wear their seatbelts — THOSE make a real obvious difference. A lot of the other stuff… less certain.

I get that there’s a lot of simple stuff, but couldn’t you deal with UTIs perfectly well without the complexity of the hospital system. Also, couldn’t someone teach that old woman how to avoid UTIs? Preventative stuff is very possible there.

I believe a lot of the problem is patients being considered to be low status in at least American culture– the lack of respect of patients’ need for sleep is an indicator.

I’ve read accounts from people who were in hospitals in other cultures (faint memory suggests that they were in Spanish-speaking countries) where the treatment was a good bit better. This was about the hospital experience, I don’t know about cure rates/lack of damage from the hospital.

UTIs don’t necessarily work that way.
The more you get them, the more susceptible you are.
Also, some women are born with short urethras which mean they’ll be getting UTIs all their life, over and over. And some women have a skewed balance of vagina flora which means they’re susceptible to UTIs.
Solving the problem of frequent UTIs takes a fair amount of trial and error and isn’t just a hygiene issue.

His claim that high fitness load means pathogen is bogus. His argument seems to be that:

– If a gene caused high fitness load, it would be eliminated by natural selection.
– Pathogens are hard to eliminate via natural selection.
– Therefore, high fitness load -> pathogen.

Which is rather non-sequiturish. A steel-man is:

1) If a high fitness load disease could be fixed by evolution, it would be.
2) Evolution is a powerful enough optimisation process to deal with most non-intelligent non-laws-of-physics high-fitness-load problems.
3) This disease doesn’t seem to be caused by a law of physics.
4) The only relevant intelligent agents around are humans and pathogen-evolution.
5) Human-caused problems have a different epistemology.
*) Therefore, the disease is caused by a pathogen.

The problematic premise seems to be 2) – it assumes that evolution faces no “engineering problems” (nothing in the laws of physics forbids 100mpg cars, or safe cheap nuclear reactors, but we can’t make these with today’s technology).

This seems to be rather weird. Of course, from the outside, it is hard to perceive engineering problems. You only notice that cars are burning fuel at low efficiencies, or that sometimes they crash into other cars – causing significant damage, or that sometimes organisms are attracted to the wrong sex, or whatever, and can easily hypothesize intelligent causes (Big Oil blocks the development of efficient cars!).

In fact, most of his arguments for the homosexuality being parasite-caused work equally well for, say, some kind of “Race Condition” that Evolution couldn’t fix (With us being barely able to notice Race Conditions in systems we build, I doubt we would notice a biological one, and Evolution doesn’t seem like a good Race-Condition-fixer).

An engineering tradeoff suggests uniformity across species, or at least nearby species. But we don’t see obligate homosexuality in chimps, nor most anywhere. Or maybe recent changes to the human brain. But it is not unique to humans, but also occurs in sheep.

Also, part of the point is that even when we observe fairly high heritability, disease can be the cause. Tuberculosis has about the same heritability as homosexuality.

Moreover, if there is no arms race with an infectious agent, the heritability should get close to zero in a way that Ewald quantifies, but never gets credit for. Either evolution can solve the problem or it should reach an optimal tradeoff. I’m not actually convinced that homosexuality or schizophrenia has non-neglible heritability, but if you believe that, infection is the only option. (Or you could argue for inclusive fitness, but that makes the numerical problems much worse.)

Humans and sheep are sufficiently different (more accurately, there are many animals “in-between” that AFAIK don’t have this problem) that I’m not sure the reasons are similar. The human brain is different enough that, especially regarding “weird” failure mode, it is a completely different game.

About heritability: certainly there couldn’t be single genes with a long-term correlations to homosexuality (otherwise we would’ve known about them). However, weird “bugs” often have weird causes.

If one wants to look inside, it would be nice to see at least both twin heritability, sibling heritability, and cross-environment heritability.

No, it’s not about transmission. If it were, the infectious agent would have been identified by now. Probably the infection occurs in childhood or maybe even prenatally. And it is probably transient.

The putative explanation is actually quite similar to Ariel’s: the brain is fragile and an infection can easily push it in certain directions, without comprehensible benefit to the infection. It might not even be the same infectious agent in all cases. It is generally accepted that this is the cause of at least some cases of narcolepsy. It’s pretty hard to believe that narcolepsy helps transmit the infection. Narcolepsy and schizophrenia are adult-onset, so it is easier to detect an infectious cause. However, my anecdotal experience is that in narcolepsy the characteristic quick onset REM starts young, and it is only the excessive daytime sleepiness which occurs abruptly in adulthood.

Homosexuality and schizophrenia are the best examples because they have the greatest evolutionary pressure, that is, the product of prevalence and fitness cost. Also, if you throw in heritability, that directly addresses Ariel’s argument: evolution does know which direction to move in. It is not just that it appears to be a high cost that evolution ought to address, but the gene pool is out of equilibrium, which suggests an arms race with another optimizer. An advantage of the example of homosexuality over schizophrenia and most mental illness is that it is hard to say what schizophrenia in animals would mean. Narcolepsy has reasonable analogues. However, Ewald mainly does not focus on mental illness.

@Army1987 — The relative infection risk of oral sex or manual stimulation is way lower than PIV or anal sex, though, and conventional wisdom is that we see roughly the same prevalence of exclusive lesbians as exclusively gay men.

No, the conventional wisdom and the truth is that bisexual men and exclusive lesbians are rare.

I don’t know why Ewald and Cochran talk about male homosexuality and not female. I don’t know any attempt at a precise comparison of fitness. As above, that might be the answer, but I suspect that they follow the conventional wisdom that lesbians are made, not born. I don’t know of any principled attempt to evaluate the evidence that produced the conventional wisdom, but I believe that the point estimate for shared environment contribution to female homosexuality is positive, while the shared environment contribution for males is zero. The error bars are pretty big, though.

This is relevant to my interests, because I was recently in the ER twice in one month. The first time I was there for five hours or so, and the second time I was there was for a shorter period of time, but came out with a prescription for a drug for acid reflux/stomach issues which I never had before. After talking to a GI specialist, it seems like a likely trigger for this new issue may have been having my sleep and eating cycle messed up by the first ER visit. (Plus the stress)

“I want to make it very clear I’m not criticizing my own hospital here. They make an amazing effort to do everything possible to avoid dangerous complications. All the hospitals I’ve worked at do. And all of them are death-traps. God just has a particular hatred for hospital patients, which He expresses by inflicting random diseases upon them for so long as they make the mistake of staying within the four walls and ceiling of a hospital building.”

*After talking to a GI specialist, it seems like a likely trigger for this new issue may have been having my sleep and eating cycle messed up by the first ER visit. *

When one of my kids was chronically ill at one point, she always got temporarily worse as soon as we checked her into the hospital, which we attributed to the stress of the environment, plus not being able to get any sleep because of all the blinking lights, the alarm monitors (which err on the side of being oversensitive, sensibly enough), and the nurses waking you up every couple of hours to take vitals and check on how you’re doing.

I knew exactly where you were going when you mentioned the Chinese room. Its pretty amazing isn’t it? And its not just medicine either, its pretty much everything in the modern world that involves multiple steps from people and companies with different expertise.

There was TED talk about how much is involved in making something as simple as a toaster (from scratch ie. from the raw materials). No one person knows how to make one, some people know one of many steps in making steel, others might know one of the steps in making plastic, but the emergent system is capable doing what no one person can. That is the magic of specialization.

This is, IMHO, one of the dominant myths of our society, and as far as I can tell, is mostly a myth. Most of the features of an industrial society can be reproduced, essentially without external outputs, in nations with strong barriers to trade. Those barriers are symptomatic of terrible internal politics, but neither the internal politics nor the barriers keeps them from having toasters.

One individual doesn’t know how to make an industrial society, but the undergrads at MIT or CMU could figure it out in a year or two, and get most of the basics worked out over Summer Vacation.

I don’t see much of a contradiction between what you said and what I said. I never said that more than one country is required to build a toaster. I said that more than one person is required and. And I never said that the process couldn’t be recreated from scratch given a reasonable amount of human capital. I said that the amount of human capital required at each stage is very low despite the task being too much for any one person to handle.

I would though, wager against a team of 10 undergraduates being able to create commercial quality toasters at a reasonable price (I would settle for 10X the price of existing toasters) within two years.

If they are totally starting from scratch, yes, it will take a long time to build an industrial society (and ‘price’ is an ambiguous concept in this scenario). If the existing manufacturers of toasters disappear but nothing else changes, it’s a summer project for one person.

For many products, I think the you’re both right as Alexander S says; possibly not one person is now able to replicate all the process for creation of [x], but it is probably possible for one person to fully understand the process. At least, our most efficient process doesn’t require anyone to know everything that is going on.

I think medicine may be more complex still, though. The scope of knowledge involved in understanding the testing involved (say, how a CT scan works, is constructed, operated, what the readings mean, etc., why this method is preferable to others), the breadth of possible dysfunctions for any and all symptom combinations, drugs and surgeries, etc. Scott does a good job of outlining the complexity, but the Chinese room experiment sells is short–a westerner is perfectly capable of becoming a fluent confucian scholar*, but no one is capable of becoming a designer of the medical industry.

*I fully expect to be informed that the intricacies of confucianism are beyond my ken, but I think the point remains.

Aliens make an exact copy of the earth as it was one million years ago and place every undergrad MIT student naked in Boston during summer and tell them they can return to the real earth after they have built a working electrical powered, metal toaster. How long, in years or generations, will it take them?

It wasn’t capable of making toast because it self-destructed too fast. Given more than 9 months and some iteration, he could have worked the bugs out of his bloom smelter and his toaster design.

More difficult is finding chisels. He didn’t need to prospect for iron or nickel, either. I think finding iron on a virgin planet isn’t that hard, but it might be. He could have instead used gold for contacts and wiring, for example, because there used to be gold nuggets littering the surface in various places.

Countries with strong barriers to trade are *poor*. India had *famines* when they closed their borders.

Consider that toaster. Mining and metalworking and polymers require specialized tools; you can’t amortize the cost unless you’re making a lot of things. Obviously Toaster Guy was rather ignorant, but even if he had been an engineer and seriously tried to self-teach, it would be really expensive to make a half-decent toaster, and if he had to build literally all his own tools, it would take a very long time. (I would expect that a couple MIT grads could make a thing that gets hot from electricity much more easily, but even then I’m not sure about the mining.)

There’s a practice in old-school ceremonial magic where you create your own ritual tools, to the extent possible, and create the tools to create the tools, and so on until you get to your own bare hands. The point is to teach something about the web of causality that underlies everyday practice, and of course to serve as a weeder.

It’s a pretty good weeder. There’s nothing as complicated as a toaster that you have to make — textiles and wood and metal utensils are about it. But if you really want virgin supplies, never touched by a human hand, that involves (e.g.) fishing bog iron nodules out of a swamp, smelting in a mud-brick furnace that you built yourself fired with charcoal that you burned yourself, beating out with stone hammers, etc… and that’s just the blade of a ceremonial knife.

India and China, at the times when they closed their borders, were substantial parts of the world population. The causal theory
Trade Barriers -> Poverty
predicts that their closing their borders should have visibly impoverished both them AND the rest of the world. By contrast,
Oppressive leadership -> Trade Barriers -> Poverty
predicts that under such conditions they would become poor while the rest of the world did not.

Another ambiguity in all this is whether you mean recreating an industrial society (able make things in large quantity at low cost) or being able to make a single industrial thing from scratch, even at very high cost.

I suspect you’re wildly underestimating the amount of very specific knowledge that goes into a factory.

I’m at the crux of deciding whether to get an MD or a PhD. (Or an MD-PhD, but that seems like a long time as a student and I’d like to be relatively youthful during the period during which I’m at peak power)

The primary draw of PhD as I see it is science, grant writing, and ideas – drawback being long hours, low pay, a long path of tedious low intensity grunt work to get there, and no respect. In that order.

The primary draw of MD as I see it is the potential for still doing translational research, high salary, higher intensity work with shorter hours, and respect – in that order. Drawbacks being …

Drawbacks being *exactly* what you wrote in this post. Dealing with the same issues, over and over again. Never really using your brain (at least, not the way you would in science). Boredom, repetition, lack of novelty, and the inability to put all these truth-discovering, paper-reading, and abstract/proposal writing skills which I’ve acquired through my idle internet time to good use.

By your writing, you appear to be more similar to me relative to the other doctors to whom I’ve spoken (none of whom I can imagine ever writing anything that they weren’t required to) so please do write a followup upon starting outpatient, and let me know if it’s any better.

Have you shadowed doctors and worked in a research lab? No need to take someone else’s word for it, start right now and experiment with different medical fields since they are all very different from each other. You should probably shadow for a fairly long time (perhaps for a week full time) to get the most out of it since things will only start to make sense after you’ve gotten used to the terminology and basic stuff.

I’ve worked in several research labs for several years now. The experience’s pleasantness seems mostly a function of who the coworkers and PI are. Everyone is really smart and even unfriendly people are a pleasure to interact with, because of rhe high level of conversation, and the reading of papers is fun, but the grunt work of actual data collection is mind numbing. I’ve published one paper.

My medical experience is less – just shadowed for 3 days. It was really fun. I dont recall much trouble with terms, however, so maybe I had the wrong kind of shadowing? I was in histology room. We poked around some intestinal tissue and chopped up this lady’s uterus and the doctors gossiped about the fact that she had so many children at this point that it wasn’t so bad to lose her uterus. Then we checked a bunch of slides for signs of cancer.

I did notice the researchers tended to be were more similar to me in personality – smart, laid back, more theoretical…whereas doctors seem more focused and practical.

A lot of folks are telling me that an M.D. is actually better from a research standpoint than a PhD if you choose a translational field…

It apparently works that way in dath ilan, and that idea certainly sounded like it made sense.

I imagine that the hard part of implementing this in real life would be figuring out how to mitigate the social and economic implications of making any kind of change to what doctors’ jobs are supposed to be (and, by extension, what their training is like).

Early diagnostic models in machine learning liked to do a two layer Bayesian network (a disease layer causing a symptom layer). If that is, to a first order, a sensible model then it seems you cannot fit good diagnostic knowledge of _everything_ into a single brain without vast simplifications. Too many parameters.

You may enjoy some of the academic literature on “distributed cognition”, analyzing the way by which systems of people carry out information-processing and achieve tasks that no one specific individual is capable of.

As one nice paper from the field, I like “Distributed Cognition in an Airline Cockpit“, which shows how even the relatively simple (as compared to running an entire hospital) process of flying a single airplane takes advantage of information-processing being distributed between a number of pilots as well as their physical environment.

Funny story: My mom once got a large, awful-looking rash with blisters on her leg and knee. We thought it might be an infection of some sort and took her to a nearby hospital. They admitted her and gave her antibiotics. A day or so later, someone figured out that the rash was actually caused by poison ivy and they stopped the antibiotics.

I’m not sure who it was that played Dr. House that time, but I guess sometimes it happens.

Incidentally, according to the internet, severe cases of poison ivy can be treated with… steroids. Go figure. (I suppose that even if antibiotics and steroids do fix everything, you still have to figure out which one to use!)

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